Provider Demographics
NPI:1215541552
Name:MIER, KLARISSA J
Entity Type:Individual
Prefix:
First Name:KLARISSA
Middle Name:J
Last Name:MIER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:KLARISSA
Other - Middle Name:J
Other - Last Name:MIER
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:2600 MARBLE AVE NE BLDG 2
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87106-2058
Mailing Address - Country:US
Mailing Address - Phone:505-306-4713
Mailing Address - Fax:
Practice Address - Street 1:2600 MARBLE AVE NE BLDG 2
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87106-2058
Practice Address - Country:US
Practice Address - Phone:505-306-4713
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-09-03
Last Update Date:2020-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM171M00000X171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator